You asked for a brief summary of New York's Long-Term Home Health Care Program, also called “Nursing Home Without Walls.”

SUMMARY

New York's Long-Term Home Health Care Program (LTHHCP, also known as “Nursing Home Without Walls”) is a federal 1915(c) Medicaid waiver program that provides comprehensive home- and community-based services to eligible seniors and individuals with disabilities who would otherwise require nursing home care. The state's health department administers the program and local social service departments implement it.

The program provides (1) care management; (2) specified Medicaid state plan services, such as nursing and personal care; (3) specified waiver services, such as medical social services and nutritional counseling; and (4) a range of optional waiver services, including home maintenance and non-medical transportation. Services may be provided in a participant's home, an adult care facility, or in a responsible adult's home. The program assesses each participant's eligibility upon application and every six months thereafter. Individual care plans the participant's physician must sign are reassessed every two months.

Because federal law requires 1915(c) Medicaid waiver programs to be cost-neutral, a participant's annual care costs cannot exceed 75% of nursing home care costs in the county in which he or she resides. (Exceptions are made for participants with special needs.) Participants who exceed this limit must disenroll from the program and obtain services through other available programs.

The New York state Medicaid program pays LTHHCP providers using a prospective, fee-for-service system. Providers must also participate in Medicare to improve continuity of care and claim Medicare revenue for participants who are eligible for both Medicaid and Medicare.

OVERVIEW

The LTHHCP is a federal 1915(c) waiver program that provides a range of home- and community-based services to help seniors and individuals with disabilities remain in the community and delay or avoid nursing home care. The program was established in 1983 and is currently authorized to operate until 2015 (waiver programs must be reauthorized every five years). The New York Department of Health administers the program, which is implemented by local social service departments (Public Health Law 3616, Social Services Law 367-c et seq., and NYCRR 505.21).

1915(c) Medicaid waiver programs allow states to waive certain Medicaid requirements in order to provide certain non-covered services to beneficiaries who would otherwise be in long-term care institutions. Unlike traditional Medicaid, waiver programs also allow states to limit services to specific populations or geographic areas.

The LTHHCP is available in all but eight New York counties and is limited to Medicaid beneficiaries who require nursing home levels of care. Program providers can administer services only to a specified number of participants at any given time (called “approved slots”). To qualify for additional slots, providers must have an aggregate occupancy rate exceeding 85% for more than one year. While the state does not maintain a program waiting list, some local LTCHHP providers do so.

The primary goals of the program are to (1) prevent or delay participants' institutionalization; (2) enable nursing home residents to safely return to the community by providing Medicaid-funded services and supports; and (3) prevent or reduce costs associated with unnecessary hospitalization through coordinated access to case management, comprehensive services, and ongoing monitoring of participants' health status.

ELIGIBILITY

LTHHCP participants must be Medicaid-eligible, need nursing home levels of care, and be able to live safely in the community. Specifically, participants must:

1. be medically eligible for nursing home placement, as determined by the health department's level of care form;

2. verify a desire to live at home and participate in the LTHHCP;

3. have an assessment from the LTHHCP provider agency, local social services department, and their physician verifying that they can remain safely at home (see below);

4. require the program's case management services and at least one waiver service each month; and

5. have a care plan that does not exceed the 75% annual budget cap (see below).

More than half of participants are referred to LTHHCP from the community (i.e., physicians, self-referrals, and other community based programs). The remainder are referred from health care institutions, such as hospitals and residential care facilities.

SERVICES

The LTHHCP provides required Medicaid state plan and waiver services (i.e., home health care services not covered by Medicaid). In addition, the program provides optional waiver services that vary by county. Table 1 provides a list of these services.

Table 1: LTHHCP Covered Services

Required Medicaid State Plan Services

Required Medicaid Waiver Services

Optional Medicaid Waiver Services

● Nursing

● Medical social services

● Assistive technology

● Physical, occupational, and speech therapies

● Nutritional counseling and education

● Community transitional services

● Medical supplies and equipment

● Respiratory therapy

● Congregate and home-delivered meals

● Audiology

● Environmental modifications

● Homemaking

● Home and community support services

● Home health and personal aides

● Home maintenance

● Moving assistance

● Respite

● Social day care

● Non-medical transportation

Source: LTHHCP Program Manual, Revised May 18, 2012

The LTHHCP provider agency and local social services department jointly assess each applicant's health, medical, nursing, social, environmental, and rehabilitative needs. They subsequently develop a care plan that includes the type, frequency, and amount of services needed to keep the applicant in the community. The LTHHCP provider agency coordinates the specific care and services included in the participant's care plan. (Participants may choose any available LTHHCP provider agency in his or her community.)

If the projected cost of these services meets the annual budget cap (see below), the applicant is approved to participate in the program. Otherwise, he or she is referred to other appropriate programs. Participants' eligibility is reassessed every six months, and care plans every two months. The participant's physician contributes to each assessment and must sign each care plan.

Upon enrollment in the program, the LTHHCP provider agency provides each participant with (1) a copy of the “Bill of Patient's Rights;” (2) a statement of available services and any related charges; (3) information on all services in the participant's care plan, including how, when, and who will provide them; and (4) information on the participant's right to participate in planning his or her care and treatment.

BUDGET CAP

The federal government requires that all 1915(c) Medicaid waiver programs be cost-neutral and gives states latitude in determining how to achieve this requirement. Unlike its other waiver programs, New York achieves LTHHCP's cost neutrality on an individual, rather than aggregate, level.

Specifically, state law requires that annual care costs for each LTHHCP participant cannot exceed 75% of the average Medicaid payment rate for nursing home care in the county in which the participant resides. Care costs may be averaged over 12 months, allowing participants to occasionally exceed their monthly budget, as long as the annual budget cap is met. Program applicants who need services exceeding this cap are ineligible to enroll. Participants who exceed this cap must disenroll from the LTHHCP and receive services through other available programs (Social Services Law § 367-c).

Exceptions to the 75% annual budget cap are made for individuals with special needs, which the law defines as (1) needing respiratory therapy, tube feeding, decubitus care (ulcers or pressure sores), or insulin therapy that cannot be provided by a personal care aide or (2) having AIDS, dementia, or a mental disability. These individual's may increase their annual budget cap to 100% of the cost of local nursing home care. Counties must limit the number of special needs individuals to 25% of their total enrollees (15% in New York City). Additional exceptions must be approved by the health department on an individual basis.

To help participants meet their annual budget cap, LTHHCP agencies try to maximize family help, third-party insurance, and use of informal community supports. For example, it may be possible to use the waiver service of “moving assistance” to relocate a participant closer to a family member; the family member is then able to provide informal support on a more frequent basis, lowering the participant's need for paid assistance.

PROVIDERS

New York's Medicaid program pays LTHHCP providers using a prospective, fee-for-service system. Rates are set based on the reported costs for the two years prior to the rate year with certain adjustments.

In addition, New York requires LTHHCP providers to also participate in the Medicare program, something that most states with similar home- and community-based programs do not require. The goal is to promote continuity of care and access to Medicare services, as well as claim Medicare revenue for LTHHCP participants who are dually eligible (i.e., eligible for both Medicaid and Medicare). This requires providers to meet additional federal reporting requirements and more stringent standards than in other programs.

RESOURCES

Medicaid Institute at United Hospital Fund, “An Overview of Medicaid Long-term Care Programs in New York: Chapter 4, Long-term Home Health Care Program,” April 2009, http://www.medicaidinstitute.org/assets/603, website last visited on November 5, 2012.